July 3, 2025 • 25 mins
| MedStar Georgetown University Hospital was the first hospital on the East Coast to offer CyberKnife technology. Our team is among the world’s most experienced CyberKnife sites having treated more than 2,400 patients with prostate cancer and performed more than 35,000 treatments in total. Unlike traditional radiation that’s given in 40 sessions over eight to nine weeks, CyberKnife can treat prostate cancer in just five visits. Dr. Jonathan Lischalk, a radiation oncologist at MedStar Georgetown, discusses CyberKnife radiation therapy for treating prostate, and the advantages of CyberKnife over conventional radiation. For an interview with Dr. Jonathan Lischalk, or for more information about this podcast, contact MedStar Georgetown University Hospital Manager Media Relations, Ryan.M.Miller2@Medstar.net. Learn more about Dr. Lischalk.
| Learn more at MedStarHealth.org/CyberKnifeNow, or call 202-444-4255.
For more episodes of MedStar Health DocTalk, go to medstarhealth.org/doctalk.
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(00:06):
Comprehensive,relevant and insightful conversations
about health and medicine happen here onMedStar Health DocTalk.
Real conversations with physician expertsfrom the largest healthcare system in
the Maryland DC region.
MedStar Georgetown University Hospitalwas the first hospital on the East coast
to offer CyberKnife technology.
Our team is among the world'smost experienced CyberKnife sites,
(00:28):
having treated more than 2,400 patientswith prostate cancer and have performed
more than 35,000 treatments in total.
You can count on our board certifiedspecialists to provide the comprehensive
and personalized carenecessary to determine the
Through our research engine, GeorgetownLombardi Comprehensive Cancer Center,
we offer access to clinical trials andthe latest breakthrough in cancer care.
(00:50):
Welcome to MedStar Health DocTalk.
I'm Ryan Miller and I'll beyour host for today's episode.
Today we're discussingCyberKnife radiation therapy
and the advantages of CyberKnifeover conventional radiation.
We are here with Dr. Jonathan Shock,our specialty service director for
the Geno Urinary Cancer Program.
Dr. Lischalk specializes in CyberKnifetreatment for men with prostate cancer.
(01:12):
In addition,he is the MedStar Health Radiation
Oncology Vice Chief of Clinical Research.
Thank you so much for joiningus on MedStar Health DocTalk.
Thanks for having me, Ryan.
So to start, I listed anumber of titles for you.
Can you walk us through thesedifferent roles that you have here?
So to start off, Ryan, Iam a radiation oncologist,
which basically means that Itreat cancers with radiation.
(01:35):
I joined MedStar Georgetown tolead the genital urinary cancer
program within radiation oncology aswell as our radiation surgery program,
which we use to treat a variety ofmalignancies, including in the prostate,
CNS brain, spine, thoracic malignancies,things like that where we use very precise
and high dose radiation to treat andcure these malignancies.
(01:57):
Another aspect to my role here atGeorgetown is to lead the research program
within our radiation oncology department,and that includes being part of the
Lombardi Cancer Center clinical Trialsoperation.
So it's been an excitingleadership opportunity and research
opportunity to really take some of thelatest and greatest in radiation oncology
(02:17):
and bring it to our patient populationhere in the Washington DC area to really
move the field forward andoptimize outcomes for patients
We're so excited to have you on our team.
Thanks again for walking us through that.
Can you tell us about the CyberKnifeprostate program here at MedStar
Georgetown?
So this is one of themost legendary programs.
(02:38):
CyberKnife has been aroundfor a couple decades now,
and it was really kicked off hereat Georgetown and a couple of other
big time institutions, Stanford at NYU.
So these are places that spearheadedand kind of pioneered this form of
technology, and essentially what itis is taking a linear accelerator,
(02:58):
which is essentially amachine that creates x-rays,
placing it on this very advanced,almost futuristic robot and moving around
a patient's body to deliver radiation,a very precise and conformal approach.
This type of radiation was originallydeveloped to treat brain and spine tumors
by a neurosurgeon at Stanford.
And over the subsequent years,we realized at the sites that I mentioned
(03:20):
that we could really treat a lot ofdifferent cancers throughout
the body using this technology.
The ability of the machine toidentify where a tumor is and
deliver radiation to that area andfrom a variety of different angles and
creating this very conformal,very precise radiation dose
distribution around the tumorallows us to optimize curative
(03:43):
radiation doses to the tumor andminimize radiation to
surrounding structures.
So it's one of these really fancyradiation machines that we have
available to treat a variety of cancers.
And what's really neat about thismachine is that as time has gone on,
we've realized all of thevarious types of cancers,
(04:05):
stages of cancers that we canuse to both cure and sometimes
palliate patients that havevariety of different malignancies.
It sounds like we have a richhistory with the CyberKnife.
For those who are unaware,what is CyberKnife and how
does it deliver the radiation?
Ryan,unlike traditional radiation that's
given in 40 sessions over eight to nineweeks, CyberKnife can treat prostate
(04:25):
cancer in just five visits with radiation.
It's a process that is minimally invasive.
So term CyberKnife is a bit of a misnomer.
There's no knife, there's no cutting,there's no pain, there's
no anesthesia. Essentially,there's a bit of a lead up to a
patient coming in for treatment,but once the patient comes in
for their actual treatment,they will meet myself and my
(04:47):
team, which is a really big team.
This type of treatmentcannot happen just on my own.
I have a team of nurses and radiationtherapists and physicists that all help
create and develop a radiation plan fora patient that's personalized and unique
to treat their specific cancer.
And so when they come in fortheir first day of treatment,
(05:07):
they'll meet this team.
They will then go into a roomwhere the CyberKnife machine is,
they will lie down on a table and theywill essentially have this machine move
over their body. They won't see anything.
They won't feel anything. Like I said,there's no cutting, there's no
pain, there's no anesthesia.
Sometimes the radiation machine willoperate for as little as 10 or 15 minutes.
Patient will get offthe table and go home,
(05:29):
and so it's almost like getting an x-ray.
It's almost like going in to get a CTscan. It's a little bit longer than that,
but you don't see anything. There'sno pain immediately afterwards,
and the patient can get off the tableand go right back to work if they want or
go home.
It's great because it has a very limitedimpact on patients and quality of life
and their day-to-day activities.
Wow, it sounds like anincredible machine for sure.
(05:50):
What are some of the benefitsof CyberKnife compared
and surgery?
CyberKnife allows fewer treatments ratherthan conventional radiation therapy,
which typically can be up to nine weeksof treatment Monday through Friday.
So this is really minimizing the amountof time that this type of treatment
takes up in a patient's daily life.
The entire treatmenttakes at max 30 minutes,
(06:12):
and because the treatment isnon-surgical, there's no anesthesia,
there's no incision,there's no blood loss.
The recovery time is basicallynon-existent. In reality,
we actually have decent data showingthat radiation side effects are really no
different than this nine week of treatmentcourse that we used to do over the
last five to 10, 20 years,and in fact might be a little bit less
than using other types of machines.
(06:34):
We are able to avoid theorgans that are nearby,
like the adjacent bladder and rectum andreally protect these normal structures
while maximizing radiation dose of theprostate and ultimately having this
technology that's ultra precise thatmonitors where the target organ the
prostate is in real time during thetreatment and between the treatments,
allows our precision delivery tominimize radiation exposure to these
(06:58):
surrounding organs and maximizeexposure to the target tissue,
which is the prostate cancer.
That's amazing that the treatmentcan take about 30 minutes,
then people can go on with their day.
Who would you say is a good candidatefor prostate cancer with CyberKnife?
What's interesting is that we've realizedalmost all stages of prostate cancer,
a patient may benefitfrom CyberKnife. Early on,
(07:18):
we focused CyberKnife SBRT on patientswith low to intermediate risk prostate
cancer, treating all those patients infive treatments. As time has gone on,
we've realized thatunfavorable intermediate risk
could benefit from this type of treatmentin a totally separate category of
patients. Oftentimes,you might see a patient that has cancer
that's spread out from where it started.
(07:39):
For example,if the prostate cancer spreads into
the lymph nodes or into the bones,there are situations where we can still
use CyberKnife to treat these areaseither in the prostate or
outside of the prostate.
So what's been very exciting over thelast five to 10 years is our ability to
expand the role of CyberKnifeSPRT to treat patients of almost
(08:00):
any stage. Obviously,this is something that we have to
discuss with the patient in detail andevaluate based on their scans
and their medical history,but I think we've really seen an
expansion in the role of CyberKnife SPRTfor a variety of stages
in prostate cancer.
How precise can the CyberKnife be?
Like we talking down to the millimeter?
Yeah, we can really get down there.
(08:22):
There's some very interesting physicsdata that's been published originally out
in California showing that onlya couple of millimeters accuracy,
precision that we're seeinghere with CyberKnife.
And this is happening notjust when a patient's set up.
It's happening between the treatmentsand happening throughout the treatment.
So as you can imagine, thepatient is under anesthesia,
there's still some movement,even a patient is trying to
lie perfectly still on a table.
(08:44):
We have motion inside of our body thatwe don't even realize our bladder is
filling, our bowels arechanging. There's gas.
There's really a change in anatomythat can occur even during treatment,
even those 15 minutes.
And so that's why the CyberKnifeplatform pioneered motion management more
so than a lot of other types of radiationmodalities very early on so that if
(09:05):
there is motion, whethera patient has to itch,
if they cough or if there's lying stilland there's just internal motion you
can't even control. The machine willsee that, it'll see it, it'll stop,
it'll reset, and that's how youget that level of precision.
That's down to the millimeter.
Wow. When it comes to pain,they might experience any
discomfort after the treatment.
There's nothing that the patient willnotice during or shortly after treatment.
(09:28):
When we think about sideeffects from radiation,
what we're thinking aboutis cumulative effects.
So it may be that towardsthe end of treatment,
a patient might notice something.
This is why our team of nurses andradiation therapists is so proactive in
making sure that patients are assessedevery single treatment that they
are evaluated for anypotential side effects,
(09:49):
even minimal changes in their qualityof life. We keep close track on,
and that can occur shortly aftertreatment or towards the end of treatment,
but oftentimes it's very minor. Now,this is something that we're not
talking about hospitalizations.
We're not talking about any types ofprocedures or surgeries that we have to do
to manage these side effects.
These are really usually minor.
(10:09):
These are things that can be managedwith adjusting somebody's diet or
fluid intake to over thecounter medications like NSAIDs,
ibuprofen, to sometimes prescriptionmedications that I can give a patient.
And so we try to tailor the approach tomanaging side effects that most often
are minor to what thepatient is experiencing. I've
(10:32):
and for the most part,people get through treatment quite
well with minimal side effects.
They may experience some things that havethem want to be closer to the bathroom
shortly after treatment, but beyond that,this isn't something where you're coming
into the hospital and you have to getmonitored in the ICU.
This is something that doesn't have amassive impact on patient's quality of
life.
That's wonderful to hear, and theycan drive themselves home afterwards,
(10:53):
so it doesn't get muchmore convenient than that.
Does CyberKnife treatment result inpositive outcomes for prostate cancer?
What we've seen over the last fiveto 10 years is really spectacular
outcomes from a cancer cure rate. Whenwe think about curing prostate cancer,
we're not talking about 1,2, 3 years down the line.
We're talking about a decade later.
(11:15):
And so as the data has accumulatedusing CyberKnife for SBRT to
treat these types of prostate cancers,we've seen outstanding outcomes.
And so when we thinkabout outcomes, of course,
the outcome for a given patient isgoing to be directly tied to the type of
cancer that they're diagnosedwith at the beginning.
So if they're screened early and theyhave a low to intermediate risk prostate
(11:35):
cancer, oftentimes we're seeingcure rates in the 90 95 percentile,
sometimes even higher. Now, that doesn'tmean patients don't need a follow up.
I am very serious about patients comingback to see us making sure that we have
any side effects or impact on theirquality of life managed. And then at the
time of followup, we'll be checking PSAs,and that's how we monitor
the response to treatment.
(11:56):
This is really the canary in the coalmine to identify if any cancer has come
back.
So we will get PSAs routinely aswe see patients and follow up and
making sure that theirPSAs stay quite low.
What's interesting is this is actuallythe same way that we monitor the response
after surgery. And so when welook at radiation versus surgery,
with the long-term randomized data thatwe've seen now published a couple of
(12:18):
times, we're seeing the same outcome.
So cancer can really be cured effectivelywith either radiation or surgery at
equal rates. So again,it's going to be tied to the type of
cancer you get diagnosed with at thebeginning. As things get a
little bit more aggressive,the cure rates go slightly lower. But
one thing I'm excited about for Ryan isthat we're trying to implement clinical
trials here at MedStar Georgetown thattake the next step for some of
(12:41):
those more aggressive cases.
And at the Lombardi CancerCenter, what we've been doing,
and I've been working witha really amazing team of
together some programs,some research and some clinical
trials that can improve outcomes forpatients to have more
aggressive prostate cancer.
And so that's what I'm really excitedfor in the future here in the next six to
(13:02):
12 months,I think we're going to be seeing some
of these clinical trials open up so thatfolks that have more aggressive prostate
cancer can really be optimized from atreatment standpoint and while paying
close attention to minimization of sideeffects and maximization
of quality of life.
That's great to knowthat if you come here,
you'll be receiving thelatest advancements when it
(13:24):
the CyberKnife treatment. Hearing.
You talk about the research,your passion is very evident.
What gets you most excited about thistype of treatment with CyberKnife?
Being a radiation oncologist is such agift. It's such a great field to be in,
and I've been passionate about itsince I first discovered the field.
One of the things that I'm so thrilledabout being an oncology is the team that
(13:45):
I work with. I mentioned theteam within radiation oncology,
which is an amazing group ofresidents and medical students and
nurses and radiationoncologists, physicists,
radiation therapists.
It's just this incredible team of folksfrom top to bottom that you get to work
with and take care of a givenpatient. And beyond that,
we work with other departments. Thereis a lot involved in treating cancer,
(14:08):
and so we have a lot of specialists thatcome to bear on a diagnosis like this,
and that includes not only radiationoncologists, but urologists,
medical oncologists,radiologists, pathologists.
So these are the folks that read thebiopsies after they're obtained or look at
the MRIs once they're obtained to seewhere the cancer is in the prostate. And
(14:29):
then the treating oncologist,including the medical
oncologist and the urologist,all of us really come into play
for a given patient's diagnosis.
A lot of folks don't realizeis that there's so much
once a patient gets diagnosedwith prostate cancer,
a lot of the times there's a lot ofcommunication that will happen before a
patient even comes intothe hospital to see us.
(14:50):
We have a conference called a tumorboard where all of these physicians sit
down and one by one,we look at cases for a given patient to
figure out what the best way to treatthem is. For example,
a patient might come in and theymight be a candidate for both surgery,
so a radical prostatectomy that'sperformed by urologist or they might be a
(15:10):
candidate for radiation.
So then how do you decide?
Well, that's a tough question,and that's really where we start
looking at the whole patient,the whole picture, what is
this patient's medical history,what is the patient's current side
effects? How is their urination pattern?
What's the patient's preference?
What would they prefer?
All of this is taken into account,and so when we're in this conference,
(15:31):
we're thinking about all that. And whenwe're seeing a patient in consultation,
these are the questions that we'reasking. So everybody's different.
Everybody's cancer is different,everybody's medical history is different.
And so the key here ispersonalization of care,
and we do that with a multidisciplinarygroup of folks that are all experts in
their field. And really the goalhere is to optimize patient outcomes.
(15:53):
Well said. Definitely not acookie cutter approach here.
Can you tell us about some of theresearch that you're involved with and
something you really think will bebeneficial down the road to patients?
Yeah, great question. When I wasbefore coming to MedStar Georgetown,
I was up in New York City and one ofthe really exciting avenues of research
that we were doing therewas optimizing radiation,
(16:16):
targeting it to the patient'sspecific area within the prostate.
So when we talk about this, let'sput it in the context of history,
we used to just treat the entire prostatejust like it was all the same in there
with radiation one dose.
But as time has gone on,we've developed newer
imaging scans and differentways to target radiation with radiation
(16:38):
planning and radiation equipment thatcan be, like I said earlier, very precise.
So how are we trying to move thefield forward? Well, we're taking,
for example,MRIs and an MRI is where you really
can see the inside of a prostate.
You can see where in the prostate,the prostate cancer is really the most
aggressive part of the prostate cancer isdeveloping.
(17:03):
And actually urologists already do this.
When they're doing the biopsy, theytake a biopsy of the whole prostate,
but then if they see somethingin the MRI that looks fishy,
they will biopsy that area alittle bit more specifically.
And once we get that informationback, we take a look and we say, okay,
so this is where the mostaggressive prostate cancer is.
So what we're trying to do in radiationoncology and what I was doing up in New
(17:25):
York City is taking thatradiological information,
which is that the targetwithin the prostate,
and pairing that with thepathological information,
which is historically we've used theterm Gleason score or grade grouping,
but also looking beyond justwhat we see in the microscope.
Looking beyond that at the actualcancer genetics and epigenetics,
(17:46):
we have some incredible tests now thatyou can send out and take a look at the
genomic signatures that a cancer has.
So we're looking at the DNA of the cancer,not the patient's
D-N-A-D-N-A of the cancer,and seeing if there's
any changes in that DNA,both the DNA itself and some
of the epigenetic changesif this is a cancer that's more or less
aggressive than some of the historicalpatterns that we've seen.
(18:11):
But what we did is look atthe genetic characteristics.
We've paired that with theradiographic characteristics,
and we've created a radiation planthat focuses some of that radiation,
like a higher dose of radiation.
The area that we see on the MR,I tie that to the genomic signatures
and kind of figure out what the dose isactually.
So rather than treating the entireprostate with one cookie cutter recipe,
(18:32):
we're taking that information that'sreally personalizing cancer care for a
patient,optimizing radiation dose to the area
we see within the MRI and kind of doingthat based on the genetic signatures.
So there's so much in medicine that'smoving so rapidly,
we didn't even touch on some of thestuff within AI that we're using now.
We have different characteristics thatwe can see on pathologic specimens that a
(18:57):
lot of stuff that'sbeen just FDA approved,
that we can look at characteristicswithin the path sample and make decisions
based on some of these valuations by ai.
We're not trying to reston our laurels here.
We're trying to move things forwardso that we can optimize treatment for
patients. Now,I talked a lot about escalating radiation
dose to the area within the prostatethat we see that harbors
(19:18):
the most aggressive disease.
But what that also means is that if wecan really escalate radiation to just
that spot,maybe we can deescalate radiation to
the rest of the area that may not be asproblematic. How can that help a patient?
Well,that could potentially lower
radiation doses to other organs.
Maybe the urethra could get a lowerdose of radiation, the bladder,
(19:40):
the rectum, every time we you'retalking about making even more precise,
even more precise,but also making sure that most of the
radiation is going to the area that needsit, and minimizing the surrendering area.
This is one of the terms that's beenused historically was focal treatment,
and that basically means radiationto a certain part of the prostate.
(20:01):
What we're doing here is kind ofcreating gradations of radiation,
heightening the radiation of the areawithin the prostate that harbors that most
aggressive disease,and kind of lowering the radiation of
the rest of the prostate that can reallylimit it and minimize some of the
toxicity that you can see with CyberKnife.
That's incredibly fascinating.
And I never thought aboutcancer as having its own DNA,
(20:21):
what a novel concept that is for anaverage show like myself, Dr. Ock,
what is the latest research shownregarding long forms of radiation,
roughly eight to nine weeks worth.
In comparison to CyberKnife? Yeah, well,that's a great point.
It's another history question almost.
When we think about deliveringradiation over nine weeks,
(20:43):
what we're doing there is going Mondaythrough Friday for nine weeks in
delivering radiation to the prostate,but kind of this radiation cloud that's
a little bit larger and less precise andalmost more ambiguous.
And the reason why we did that isthat we just didn't have the imaging.
We didn't have MRIs, we didn't haveadvanced machines like CyberKnife.
We didn't have ways to track radiationtreatment during the delivery of it.
(21:05):
And so as a result, the cloudof radiation was a lot larger.
And so when you're gettingthat nine weeks of treatment,
that's a larger radiationcloud. And because of that,
that's why you have to separate itout in those 40 plus treatments.
What's interesting with CyberKnife isthat, as we talked about, the precision,
the monitoring of motion, thetreatment planning that's advanced,
the use of MRIs,all these things that take
(21:26):
the most advanced equipmenttight in that radiation cloud. It's
really just surrounding the prostate withabout a millimeter, a
couple of millimeters there,and that allows us to deliver radiation
and a larger dose of radiation a veryquick way. So five treatments
over about a week and a half,and we've known here at Georgetown that
the outcomes have been outstanding.
(21:50):
But what's interesting more broadly isthat now we have randomized data as an
oncologist and a researcher.
The gold standard is randomizingdata to figure out which is better.
It's going head to head.
This is head to head comparing longercourses of radiation with short
course radiation.
And what's really exciting in the lastcouple of years is that we have that now.
(22:12):
It's been done. It's beendone a couple times now,
and what we see is thatCyberKnife is a winner.
We're seeing cancer outcomes that arebasically the same long term. We're
talking about five to 10 years here.
We're seeing side effect profilesthat are basically the same.
We're seeing quality of lifeprofiles that are very similar.
The most recent publication that wasin the New England Journal of Medicine,
(22:33):
which is really the best journalthat we have in medicine.
It shows exactly what I just said.
And this was an amazing trial publishedout of the UK by a friend of mine and
showed that CyberKnife is an outstandingway to treat localized prostate cancer.
And so we now have the data to say,well, we don't need the nine weeks.
We can really go forward withthe five days of treatment.
(22:54):
And what's even more interesting andprovocative is that that trial initially
mandated people to use CyberKnife.
It was actually an expectation in Englandfor them to use it because they felt
that that was the technology thatmight be an optimal way to treat.
And there is some indication thatpatients that got CyberKnife on that trial
might've done a little bit betterfrom a toxicity standpoint,
side effects standpoint.
(23:15):
So that's why we're really excited aboutbeing able to offer it here at MedStar
Georgetown.
Why should a patient choose theradiation oncology department at MedStar,
Georgetown University Hospital? Ryan?
We talked a lot abouttechnology and history and
experience, and I think thatis really, really important.
But maybe the most important thing inmy opinion that we have here at MedStar
(23:36):
Georgetown and the LombardiComprehensive Cancer Center,
really the only NCI cancer centerin the region is a group of people,
a group of specialists,a multidisciplinary group of folks
who are here to treat and cure cancerand optimize the quality of life for
patients. And so every day when I go in,it's a team of people from within our
department and between departments thatlooks at a given patient and tries to
(23:58):
figure out the best way to treat them,which regardless of whether I treat them
with radiation or a medical oncologistthat gives them targeted therapy or
drug therapy or a urologist performs aprostatectomy, we're really not trying
to offer a cookie cutter approach here.
We are trying to take the best mindsthat we have and come up with a
(24:21):
personalized and optimizedtreatment plan for every patient.
And I think that's probably the mostexciting and most important aspect to our
MedStar Georgetown philosophy.
No matter what is ailing you,we've got you covered at MedStar
Georgetown University Hospital.
I've learned a lot in our conversationtoday. So thank you so much,
Dr. Lischalk, for your time.
I've been talking with Dr. JonathanLischalk at MedStar Georgetown University
(24:42):
Hospital in Washington,DC Thanks again for sharing your expertise
with us on MedStar Health Doc Doc.
Thanks for having me, Ryan.
Learn more at MedStarhealth.org/cyberknife or call
2 0 2 4 4 4 4 2 5 5.
Comprehensive,relevant and insightful conversations
about health and medicine happen here onMedStar Health DocTalk.
Real conversations with physician expertsfrom the largest healthcare system in
the Maryland DC region.
MedStar Georgetown University Hospitalwas the first hospital on the East coast
to offer CyberKnife technology.
Our team is among the world'smost experienced CyberKnife sites,
(00:28):
having treated more than 2,400 patientswith prostate cancer and have performed
more than 35,000 treatments in total.
You can count on our board certifiedspecialists to provide the comprehensive
and personalized carenecessary to determine the
Through our research engine, GeorgetownLombardi Comprehensive Cancer Center,
we offer access to clinical trials andthe latest breakthrough in cancer care.
(00:50):
Welcome to MedStar Health DocTalk.
I'm Ryan Miller and I'll beyour host for today's episode.
Today we're discussingCyberKnife radiation therapy
and the advantages of CyberKnifeover conventional radiation.
We are here with Dr. Jonathan Shock,our specialty service director for
the Geno Urinary Cancer Program.
Dr. Lischalk specializes in CyberKnifetreatment for men with prostate cancer.
(01:12):
In addition,he is the MedStar Health Radiation
Oncology Vice Chief of Clinical Research.
Thank you so much for joiningus on MedStar Health DocTalk.
Thanks for having me, Ryan.
So to start, I listed anumber of titles for you.
Can you walk us through thesedifferent roles that you have here?
So to start off, Ryan, Iam a radiation oncologist,
which basically means that Itreat cancers with radiation.
(01:35):
I joined MedStar Georgetown tolead the genital urinary cancer
program within radiation oncology aswell as our radiation surgery program,
which we use to treat a variety ofmalignancies, including in the prostate,
CNS brain, spine, thoracic malignancies,things like that where we use very precise
and high dose radiation to treat andcure these malignancies.
(01:57):
Another aspect to my role here atGeorgetown is to lead the research program
within our radiation oncology department,and that includes being part of the
Lombardi Cancer Center clinical Trialsoperation.
So it's been an excitingleadership opportunity and research
opportunity to really take some of thelatest and greatest in radiation oncology
(02:17):
and bring it to our patient populationhere in the Washington DC area to really
move the field forward andoptimize outcomes for patients
We're so excited to have you on our team.
Thanks again for walking us through that.
Can you tell us about the CyberKnifeprostate program here at MedStar
Georgetown?
So this is one of themost legendary programs.
(02:38):
CyberKnife has been aroundfor a couple decades now,
and it was really kicked off hereat Georgetown and a couple of other
big time institutions, Stanford at NYU.
So these are places that spearheadedand kind of pioneered this form of
technology, and essentially what itis is taking a linear accelerator,
(02:58):
which is essentially amachine that creates x-rays,
placing it on this very advanced,almost futuristic robot and moving around
a patient's body to deliver radiation,a very precise and conformal approach.
This type of radiation was originallydeveloped to treat brain and spine tumors
by a neurosurgeon at Stanford.
And over the subsequent years,we realized at the sites that I mentioned
(03:20):
that we could really treat a lot ofdifferent cancers throughout
the body using this technology.
The ability of the machine toidentify where a tumor is and
deliver radiation to that area andfrom a variety of different angles and
creating this very conformal,very precise radiation dose
distribution around the tumorallows us to optimize curative
(03:43):
radiation doses to the tumor andminimize radiation to
surrounding structures.
So it's one of these really fancyradiation machines that we have
available to treat a variety of cancers.
And what's really neat about thismachine is that as time has gone on,
we've realized all of thevarious types of cancers,
(04:05):
stages of cancers that we canuse to both cure and sometimes
palliate patients that havevariety of different malignancies.
It sounds like we have a richhistory with the CyberKnife.
For those who are unaware,what is CyberKnife and how
does it deliver the radiation?
Ryan,unlike traditional radiation that's
given in 40 sessions over eight to nineweeks, CyberKnife can treat prostate
(04:25):
cancer in just five visits with radiation.
It's a process that is minimally invasive.
So term CyberKnife is a bit of a misnomer.
There's no knife, there's no cutting,there's no pain, there's
no anesthesia. Essentially,there's a bit of a lead up to a
patient coming in for treatment,but once the patient comes in
for their actual treatment,they will meet myself and my
(04:47):
team, which is a really big team.
This type of treatmentcannot happen just on my own.
I have a team of nurses and radiationtherapists and physicists that all help
create and develop a radiation plan fora patient that's personalized and unique
to treat their specific cancer.
And so when they come in fortheir first day of treatment,
(05:07):
they'll meet this team.
They will then go into a roomwhere the CyberKnife machine is,
they will lie down on a table and theywill essentially have this machine move
over their body. They won't see anything.
They won't feel anything. Like I said,there's no cutting, there's no
pain, there's no anesthesia.
Sometimes the radiation machine willoperate for as little as 10 or 15 minutes.
Patient will get offthe table and go home,
(05:29):
and so it's almost like getting an x-ray.
It's almost like going in to get a CTscan. It's a little bit longer than that,
but you don't see anything. There'sno pain immediately afterwards,
and the patient can get off the tableand go right back to work if they want or
go home.
It's great because it has a very limitedimpact on patients and quality of life
and their day-to-day activities.
Wow, it sounds like anincredible machine for sure.
(05:50):
What are some of the benefitsof CyberKnife compared
and surgery?
CyberKnife allows fewer treatments ratherthan conventional radiation therapy,
which typically can be up to nine weeksof treatment Monday through Friday.
So this is really minimizing the amountof time that this type of treatment
takes up in a patient's daily life.
The entire treatmenttakes at max 30 minutes,
(06:12):
and because the treatment isnon-surgical, there's no anesthesia,
there's no incision,there's no blood loss.
The recovery time is basicallynon-existent. In reality,
we actually have decent data showingthat radiation side effects are really no
different than this nine week of treatmentcourse that we used to do over the
last five to 10, 20 years,and in fact might be a little bit less
than using other types of machines.
(06:34):
We are able to avoid theorgans that are nearby,
like the adjacent bladder and rectum andreally protect these normal structures
while maximizing radiation dose of theprostate and ultimately having this
technology that's ultra precise thatmonitors where the target organ the
prostate is in real time during thetreatment and between the treatments,
allows our precision delivery tominimize radiation exposure to these
(06:58):
surrounding organs and maximizeexposure to the target tissue,
which is the prostate cancer.
That's amazing that the treatmentcan take about 30 minutes,
then people can go on with their day.
Who would you say is a good candidatefor prostate cancer with CyberKnife?
What's interesting is that we've realizedalmost all stages of prostate cancer,
a patient may benefitfrom CyberKnife. Early on,
(07:18):
we focused CyberKnife SBRT on patientswith low to intermediate risk prostate
cancer, treating all those patients infive treatments. As time has gone on,
we've realized thatunfavorable intermediate risk
could benefit from this type of treatmentin a totally separate category of
patients. Oftentimes,you might see a patient that has cancer
that's spread out from where it started.
(07:39):
For example,if the prostate cancer spreads into
the lymph nodes or into the bones,there are situations where we can still
use CyberKnife to treat these areaseither in the prostate or
outside of the prostate.
So what's been very exciting over thelast five to 10 years is our ability to
expand the role of CyberKnifeSPRT to treat patients of almost
(08:00):
any stage. Obviously,this is something that we have to
discuss with the patient in detail andevaluate based on their scans
and their medical history,but I think we've really seen an
expansion in the role of CyberKnife SPRTfor a variety of stages
in prostate cancer.
How precise can the CyberKnife be?
Like we talking down to the millimeter?
Yeah, we can really get down there.
(08:22):
There's some very interesting physicsdata that's been published originally out
in California showing that onlya couple of millimeters accuracy,
precision that we're seeinghere with CyberKnife.
And this is happening notjust when a patient's set up.
It's happening between the treatmentsand happening throughout the treatment.
So as you can imagine, thepatient is under anesthesia,
there's still some movement,even a patient is trying to
lie perfectly still on a table.
(08:44):
We have motion inside of our body thatwe don't even realize our bladder is
filling, our bowels arechanging. There's gas.
There's really a change in anatomythat can occur even during treatment,
even those 15 minutes.
And so that's why the CyberKnifeplatform pioneered motion management more
so than a lot of other types of radiationmodalities very early on so that if
(09:05):
there is motion, whethera patient has to itch,
if they cough or if there's lying stilland there's just internal motion you
can't even control. The machine willsee that, it'll see it, it'll stop,
it'll reset, and that's how youget that level of precision.
That's down to the millimeter.
Wow. When it comes to pain,they might experience any
discomfort after the treatment.
There's nothing that the patient willnotice during or shortly after treatment.
(09:28):
When we think about sideeffects from radiation,
what we're thinking aboutis cumulative effects.
So it may be that towardsthe end of treatment,
a patient might notice something.
This is why our team of nurses andradiation therapists is so proactive in
making sure that patients are assessedevery single treatment that they
are evaluated for anypotential side effects,
(09:49):
even minimal changes in their qualityof life. We keep close track on,
and that can occur shortly aftertreatment or towards the end of treatment,
but oftentimes it's very minor. Now,this is something that we're not
talking about hospitalizations.
We're not talking about any types ofprocedures or surgeries that we have to do
to manage these side effects.
These are really usually minor.
(10:09):
These are things that can be managedwith adjusting somebody's diet or
fluid intake to over thecounter medications like NSAIDs,
ibuprofen, to sometimes prescriptionmedications that I can give a patient.
And so we try to tailor the approach tomanaging side effects that most often
are minor to what thepatient is experiencing. I've
(10:32):
and for the most part,people get through treatment quite
well with minimal side effects.
They may experience some things that havethem want to be closer to the bathroom
shortly after treatment, but beyond that,this isn't something where you're coming
into the hospital and you have to getmonitored in the ICU.
This is something that doesn't have amassive impact on patient's quality of
life.
That's wonderful to hear, and theycan drive themselves home afterwards,
(10:53):
so it doesn't get muchmore convenient than that.
Does CyberKnife treatment result inpositive outcomes for prostate cancer?
What we've seen over the last fiveto 10 years is really spectacular
outcomes from a cancer cure rate. Whenwe think about curing prostate cancer,
we're not talking about 1,2, 3 years down the line.
We're talking about a decade later.
(11:15):
And so as the data has accumulatedusing CyberKnife for SBRT to
treat these types of prostate cancers,we've seen outstanding outcomes.
And so when we thinkabout outcomes, of course,
the outcome for a given patient isgoing to be directly tied to the type of
cancer that they're diagnosedwith at the beginning.
So if they're screened early and theyhave a low to intermediate risk prostate
(11:35):
cancer, oftentimes we're seeingcure rates in the 90 95 percentile,
sometimes even higher. Now, that doesn'tmean patients don't need a follow up.
I am very serious about patients comingback to see us making sure that we have
any side effects or impact on theirquality of life managed. And then at the
time of followup, we'll be checking PSAs,and that's how we monitor
the response to treatment.
(11:56):
This is really the canary in the coalmine to identify if any cancer has come
back.
So we will get PSAs routinely aswe see patients and follow up and
making sure that theirPSAs stay quite low.
What's interesting is this is actuallythe same way that we monitor the response
after surgery. And so when welook at radiation versus surgery,
with the long-term randomized data thatwe've seen now published a couple of
(12:18):
times, we're seeing the same outcome.
So cancer can really be cured effectivelywith either radiation or surgery at
equal rates. So again,it's going to be tied to the type of
cancer you get diagnosed with at thebeginning. As things get a
little bit more aggressive,the cure rates go slightly lower. But
one thing I'm excited about for Ryan isthat we're trying to implement clinical
trials here at MedStar Georgetown thattake the next step for some of
(12:41):
those more aggressive cases.
And at the Lombardi CancerCenter, what we've been doing,
and I've been working witha really amazing team of
together some programs,some research and some clinical
trials that can improve outcomes forpatients to have more
aggressive prostate cancer.
And so that's what I'm really excitedfor in the future here in the next six to
(13:02):
12 months,I think we're going to be seeing some
of these clinical trials open up so thatfolks that have more aggressive prostate
cancer can really be optimized from atreatment standpoint and while paying
close attention to minimization of sideeffects and maximization
of quality of life.
That's great to knowthat if you come here,
you'll be receiving thelatest advancements when it
(13:24):
the CyberKnife treatment. Hearing.
You talk about the research,your passion is very evident.
What gets you most excited about thistype of treatment with CyberKnife?
Being a radiation oncologist is such agift. It's such a great field to be in,
and I've been passionate about itsince I first discovered the field.
One of the things that I'm so thrilledabout being an oncology is the team that
(13:45):
I work with. I mentioned theteam within radiation oncology,
which is an amazing group ofresidents and medical students and
nurses and radiationoncologists, physicists,
radiation therapists.
It's just this incredible team of folksfrom top to bottom that you get to work
with and take care of a givenpatient. And beyond that,
we work with other departments. Thereis a lot involved in treating cancer,
(14:08):
and so we have a lot of specialists thatcome to bear on a diagnosis like this,
and that includes not only radiationoncologists, but urologists,
medical oncologists,radiologists, pathologists.
So these are the folks that read thebiopsies after they're obtained or look at
the MRIs once they're obtained to seewhere the cancer is in the prostate. And
(14:29):
then the treating oncologist,including the medical
oncologist and the urologist,all of us really come into play
for a given patient's diagnosis.
A lot of folks don't realizeis that there's so much
once a patient gets diagnosedwith prostate cancer,
a lot of the times there's a lot ofcommunication that will happen before a
patient even comes intothe hospital to see us.
(14:50):
We have a conference called a tumorboard where all of these physicians sit
down and one by one,we look at cases for a given patient to
figure out what the best way to treatthem is. For example,
a patient might come in and theymight be a candidate for both surgery,
so a radical prostatectomy that'sperformed by urologist or they might be a
(15:10):
candidate for radiation.
So then how do you decide?
Well, that's a tough question,and that's really where we start
looking at the whole patient,the whole picture, what is
this patient's medical history,what is the patient's current side
effects? How is their urination pattern?
What's the patient's preference?
What would they prefer?
All of this is taken into account,and so when we're in this conference,
(15:31):
we're thinking about all that. And whenwe're seeing a patient in consultation,
these are the questions that we'reasking. So everybody's different.
Everybody's cancer is different,everybody's medical history is different.
And so the key here ispersonalization of care,
and we do that with a multidisciplinarygroup of folks that are all experts in
their field. And really the goalhere is to optimize patient outcomes.
(15:53):
Well said. Definitely not acookie cutter approach here.
Can you tell us about some of theresearch that you're involved with and
something you really think will bebeneficial down the road to patients?
Yeah, great question. When I wasbefore coming to MedStar Georgetown,
I was up in New York City and one ofthe really exciting avenues of research
that we were doing therewas optimizing radiation,
(16:16):
targeting it to the patient'sspecific area within the prostate.
So when we talk about this, let'sput it in the context of history,
we used to just treat the entire prostatejust like it was all the same in there
with radiation one dose.
But as time has gone on,we've developed newer
imaging scans and differentways to target radiation with radiation
(16:38):
planning and radiation equipment thatcan be, like I said earlier, very precise.
So how are we trying to move thefield forward? Well, we're taking,
for example,MRIs and an MRI is where you really
can see the inside of a prostate.
You can see where in the prostate,the prostate cancer is really the most
aggressive part of the prostate cancer isdeveloping.
(17:03):
And actually urologists already do this.
When they're doing the biopsy, theytake a biopsy of the whole prostate,
but then if they see somethingin the MRI that looks fishy,
they will biopsy that area alittle bit more specifically.
And once we get that informationback, we take a look and we say, okay,
so this is where the mostaggressive prostate cancer is.
So what we're trying to do in radiationoncology and what I was doing up in New
(17:25):
York City is taking thatradiological information,
which is that the targetwithin the prostate,
and pairing that with thepathological information,
which is historically we've used theterm Gleason score or grade grouping,
but also looking beyond justwhat we see in the microscope.
Looking beyond that at the actualcancer genetics and epigenetics,
(17:46):
we have some incredible tests now thatyou can send out and take a look at the
genomic signatures that a cancer has.
So we're looking at the DNA of the cancer,not the patient's
D-N-A-D-N-A of the cancer,and seeing if there's
any changes in that DNA,both the DNA itself and some
of the epigenetic changesif this is a cancer that's more or less
aggressive than some of the historicalpatterns that we've seen.
(18:11):
But what we did is look atthe genetic characteristics.
We've paired that with theradiographic characteristics,
and we've created a radiation planthat focuses some of that radiation,
like a higher dose of radiation.
The area that we see on the MR,I tie that to the genomic signatures
and kind of figure out what the dose isactually.
So rather than treating the entireprostate with one cookie cutter recipe,
(18:32):
we're taking that information that'sreally personalizing cancer care for a
patient,optimizing radiation dose to the area
we see within the MRI and kind of doingthat based on the genetic signatures.
So there's so much in medicine that'smoving so rapidly,
we didn't even touch on some of thestuff within AI that we're using now.
We have different characteristics thatwe can see on pathologic specimens that a
(18:57):
lot of stuff that'sbeen just FDA approved,
that we can look at characteristicswithin the path sample and make decisions
based on some of these valuations by ai.
We're not trying to reston our laurels here.
We're trying to move things forwardso that we can optimize treatment for
patients. Now,I talked a lot about escalating radiation
dose to the area within the prostatethat we see that harbors
(19:18):
the most aggressive disease.
But what that also means is that if wecan really escalate radiation to just
that spot,maybe we can deescalate radiation to
the rest of the area that may not be asproblematic. How can that help a patient?
Well,that could potentially lower
radiation doses to other organs.
Maybe the urethra could get a lowerdose of radiation, the bladder,
(19:40):
the rectum, every time we you'retalking about making even more precise,
even more precise,but also making sure that most of the
radiation is going to the area that needsit, and minimizing the surrendering area.
This is one of the terms that's beenused historically was focal treatment,
and that basically means radiationto a certain part of the prostate.
(20:01):
What we're doing here is kind ofcreating gradations of radiation,
heightening the radiation of the areawithin the prostate that harbors that most
aggressive disease,and kind of lowering the radiation of
the rest of the prostate that can reallylimit it and minimize some of the
toxicity that you can see with CyberKnife.
That's incredibly fascinating.
And I never thought aboutcancer as having its own DNA,
(20:21):
what a novel concept that is for anaverage show like myself, Dr. Ock,
what is the latest research shownregarding long forms of radiation,
roughly eight to nine weeks worth.
In comparison to CyberKnife? Yeah, well,that's a great point.
It's another history question almost.
When we think about deliveringradiation over nine weeks,
(20:43):
what we're doing there is going Mondaythrough Friday for nine weeks in
delivering radiation to the prostate,but kind of this radiation cloud that's
a little bit larger and less precise andalmost more ambiguous.
And the reason why we did that isthat we just didn't have the imaging.
We didn't have MRIs, we didn't haveadvanced machines like CyberKnife.
We didn't have ways to track radiationtreatment during the delivery of it.
(21:05):
And so as a result, the cloudof radiation was a lot larger.
And so when you're gettingthat nine weeks of treatment,
that's a larger radiationcloud. And because of that,
that's why you have to separate itout in those 40 plus treatments.
What's interesting with CyberKnife isthat, as we talked about, the precision,
the monitoring of motion, thetreatment planning that's advanced,
the use of MRIs,all these things that take
(21:26):
the most advanced equipmenttight in that radiation cloud. It's
really just surrounding the prostate withabout a millimeter, a
couple of millimeters there,and that allows us to deliver radiation
and a larger dose of radiation a veryquick way. So five treatments
over about a week and a half,and we've known here at Georgetown that
the outcomes have been outstanding.
(21:50):
But what's interesting more broadly isthat now we have randomized data as an
oncologist and a researcher.
The gold standard is randomizingdata to figure out which is better.
It's going head to head.
This is head to head comparing longercourses of radiation with short
course radiation.
And what's really exciting in the lastcouple of years is that we have that now.
(22:12):
It's been done. It's beendone a couple times now,
and what we see is thatCyberKnife is a winner.
We're seeing cancer outcomes that arebasically the same long term. We're
talking about five to 10 years here.
We're seeing side effect profilesthat are basically the same.
We're seeing quality of lifeprofiles that are very similar.
The most recent publication that wasin the New England Journal of Medicine,
(22:33):
which is really the best journalthat we have in medicine.
It shows exactly what I just said.
And this was an amazing trial publishedout of the UK by a friend of mine and
showed that CyberKnife is an outstandingway to treat localized prostate cancer.
And so we now have the data to say,well, we don't need the nine weeks.
We can really go forward withthe five days of treatment.
(22:54):
And what's even more interesting andprovocative is that that trial initially
mandated people to use CyberKnife.
It was actually an expectation in Englandfor them to use it because they felt
that that was the technology thatmight be an optimal way to treat.
And there is some indication thatpatients that got CyberKnife on that trial
might've done a little bit betterfrom a toxicity standpoint,
side effects standpoint.
(23:15):
So that's why we're really excited aboutbeing able to offer it here at MedStar
Georgetown.
Why should a patient choose theradiation oncology department at MedStar,
Georgetown University Hospital? Ryan?
We talked a lot abouttechnology and history and
experience, and I think thatis really, really important.
But maybe the most important thing inmy opinion that we have here at MedStar
(23:36):
Georgetown and the LombardiComprehensive Cancer Center,
really the only NCI cancer centerin the region is a group of people,
a group of specialists,a multidisciplinary group of folks
who are here to treat and cure cancerand optimize the quality of life for
patients. And so every day when I go in,it's a team of people from within our
department and between departments thatlooks at a given patient and tries to
(23:58):
figure out the best way to treat them,which regardless of whether I treat them
with radiation or a medical oncologistthat gives them targeted therapy or
drug therapy or a urologist performs aprostatectomy, we're really not trying
to offer a cookie cutter approach here.
We are trying to take the best mindsthat we have and come up with a
(24:21):
personalized and optimizedtreatment plan for every patient.
And I think that's probably the mostexciting and most important aspect to our
MedStar Georgetown philosophy.
No matter what is ailing you,we've got you covered at MedStar
Georgetown University Hospital.
I've learned a lot in our conversationtoday. So thank you so much,
Dr. Lischalk, for your time.
I've been talking with Dr. JonathanLischalk at MedStar Georgetown University
(24:42):
Hospital in Washington,DC Thanks again for sharing your expertise
with us on MedStar Health Doc Doc.
Thanks for having me, Ryan.
Learn more at MedStarhealth.org/cyberknife or call
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